EyeWorld India December 2017 Issue

December 2017 EWAP FEATURE 21 endothelial keratoplasty [DESK], staging the phaco first is helpful so that when the corneal graft is being done, that’s all the surgeon has to focus on,” Dr. Chan said. “In DMEK, it is helpful for the pupil to be constricted, and if done in combination with phaco, where the pupil has to be dilated, it can make the DMEK more challenging.” However, if a patient has morn- ing blur complaints and known Fuchs’ dystrophy with cataract, she recommends a combination surgery. Dr. Yeu agreed. “The more that they’re having clinical signs of corneal edema, the more likely it is I’ll do a combined procedure versus cataract surgery alone,” Dr. Yeu said. “If it’s a gradual decline in vision, and corneal disease is not as severe based on clinical exam, I lean toward cataract surgery only,” Dr. Mian said. “This is where [obtaining] endothelial cell density may be helpful.” If corneal endothelial disease is less severe, Dr. Mian prefers to perform DMEK; in advanced cases with moderate to severe edema or scarring, his choice is DSEK. Although there has been a lot of buzz about femtosecond laser- assisted cataract surgery (FLACS), its advantages are not necessarily as valuable in patients with concur- rent endothelial disease. “It could minimize ultrasound energy use, but it depends on the density of the lens,” Dr. Mian said. “Femtosecond phaco is not covered by any insurance, so cost becomes a factor. I do use a dispersive viscoe- lastic to protect the endothelium.” If a patient has some endothe- lial dysfunction but can have cataract surgery alone, Dr. Yeu will use FLACS. However, if combining cataract surgery with an EK, she will use manual cataract surgery. Dr. Chan also sees the advantage of using less phaco energy to emulsi- fy a cataract, especially a dense one, thereby helping to preserve the cor- neal endothelium. However, “Femto wounds can cause more endothelial apoptosis, so I would not use the femto laser to create incisions in pa- tients with a compromised corneal endothelium,” she said. EWAP Editors’ note: The physicians have no financial interests related to their com- ments. Contact information Chan: clarachanmd@gmail.com Mian: smian@umich.edu Yeu: eyeulin@gmail.com